Consultant Anthony Stock told the inquest the care should have been "consultant-led at the outset".

Miss McCall, now 18, was not given the one-to-one midwife care she needed because of a lack of staff, the inquest heard.

She was initially denied the Caesarean she wanted after being admitted to the hospital on 8 May with severe stomach pains, the inquest was told.

Erratic heartbeat

Ms McCall, who suffers from a narrow pulmonary valve and only has one kidney, was told by medical staff that the emergency Caesarean would be too risky, despite her own midwife supporting the request.

Instead, she was advised to have an induced birth to ease her symptoms, but she refused because of the pain she was in, the hearing heard.

Ebony was born pale and floppy on 9 May, and had an erratic heartbeat and was pronounced dead half an hour later.

She had suffered brain damage due to a lack of oxygen, a pathologist told the inquest.

Mr Stock said: "I am happy to acknowledge that the care did not come up to a standard that I would have expected normally for a patient booked in my name."

He told the inquest Miss McCall was considered "low risk" in cardiac terms but when she came into hospital with stomach pain, would have been "high risk".

Last year, Deputy Coroner for Milton Keynes Thomas Osborne reported the hospital to the Department of Health after the death of baby Romy Feast, who was born by Caesarean section at the hospital in 2007 but died after her cardiotocography (CTG) was misinterpreted.

A Healthcare Commission investigation was launched and Mr Osborne told the hearing the 2008 report found many recommendations had not been met.

Bed numbers

He said the report said there appeared to be a high degree of pressure on bed occupancy and more than one midwife had expressed concerns that mothers and their babies were being discharged early, leading to a higher-than-average readmission rate.

Mr Osborne also told the inquest recommendations about bed numbers had not been met.

Mr Stock added: "Milton Keynes is not unique. We have a scenario where we have not just got an increasing birth rate but increasing complexity.

"We have not managed to keep up despite a lot of hard work on the part of the midwifery managers.

"I think everyone acknowledges within the department that we do need to have higher staffing levels and more space."

Head of midwifery services Elizabeth Hunter told the inquest standards of care had not been met the night Miss McCall gave birth.

The inquest heard funding was available to employ more midwives, but the hospital struggled to recruit.

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